Intramedullary headless compression screws (IHCS) and dorsal plates are both established implants for operative fixation of metacarpal shaft fractures, but their comparative effects on radiological and clinical outcomes remain incompletely documented. We retrospectively reviewed 109 patients treated between 2014 and 2024 at our institution: 28 patients in the IHCS group and 81 patients in the plate group. Metacarpal length was assessed using a radiographic prediction model. The IHCS group showed a significantly greater absolute deviation from predicted metacarpal length (1.7 mm (95% CI 1.1 to 2.3) versus 0.8 mm (95% CI 0.7 to 1.0), p = 0.007), and shortening was more frequent than lengthening in both groups, with a significantly higher shortening in the IHCS group (-1.1 mm (95% CI -1.9 to -0.3) versus -0.2 mm (95% CI -0.4 to 0.0), p = 0.040). Despite this radiological difference, no statistically significant differences in total active motion (258° vs 266°, p = 0.345), fist closure rate (100% vs 96%, p = 0.900), rotational deformity (0/13 vs 1/33, p = 0.536) and grip strength relative to the contralateral hand (94% vs 99% in dominant-hand injuries, p = 0.496) were detected between the two groups. No nonunions occurred in either group. In the plate group, 36 patients (44%) underwent hardware removal; only one secondary procedure (tenolysis) was required in the IHCS group. The greater shortening observed after IHCS is biomechanically consistent with the compressive properties of this intramedullary implant. In conclusion, dorsal plating may provide more predictable length restoration, whereas IHCS fixation may decrease the need for secondary implant removal.

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